Pes Anserine Bursitis - Brigham and Women's Hospital

Department of Rehabilitation Services 

Physical Therapy 

Standard of Care: Pes Anserine Bursitis 

Diagnosis: 

Pes anserine bursitis ICD- 9 Code 726.61 

The pes anserine bursa lies behind the medial hamstring, which is composed of the tendons of 

the sartorius, gracilis and semitendinosus (SGT) muscles. Because these 3 tendons splay out on 

the anterior aspect of the tibia and give the appearance of the foot of a goose, pes anserine 

bursitis is also known as goosefoot bursitis. 1 These muscles provide for medial stabilization of 

the knee by acting as a restraint to excessive valgus opening. They also provide a counter-rotary 

torque function to the knee joint. The pes anserine has an eccentric role during the screw-home 

mechanism that dampens the effect of excessively forceful lateral rotation that may accompany 

terminal knee extension. 2 

Pes anserine bursitis presents as pain, tenderness and swelling over the anteromedial aspect of 

the knee, 4 to 5 cm below the joint line. 3 Pain increases with knee flexion, exercise and/or stair 

climbing. Inflammation of this bursa is common in overweight, middle-aged women, and may be 

associated with osteoarthritis of the knee. It also occurs in athletes engaged in activities such as 

running, basketball, and racquet sports. 3 

Other risk factors include: 1 

• Incorrect training techniques, or changes in terrain and/or distanced run 

• Lack of flexibility in hamstring muscles 

• Lack of knee extension 

• Patellar malalignment 

Indications for Treatment: 

• Knee Pain 

• Knee edema 

• Decreased active and /or passive ROM of lower extremities 

• Biomechanical dysfunction lower extremities 

• Muscle imbalances 

• Impaired muscle performance (focal weakness or general conditioning) 

• Impaired function 

Contraindications: 

Patients with active signs/symptoms of infection (fever, chills, prolonged and obvious redness or 

swelling at hip joint). 


Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation 

Services. All rights reserved. 

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Precautions for Treatment: 

• OA-presence of osteophytes must be taken into account when establishing goals 

and treatment plan 

• RA-patient may be at greater risk of infection; cyst formation may appear on 

radiograph, and the cyst may communicate with bursa 

• DM-increased risk of infection 

• Refer to modality practice standards for other contraindications and precautions 

Examination: 

Past Medical History: 

• Previous repetitive strain/overuse injuries involving lower extremities 

• Trauma to lower extremities 

• Systemic disease process (eg. RA, DM, connective tissue disorders) 

• Osteoarthritis 

History of Present Illness: 

• Location of pain and pain level 

• Inciting events or precipitating activities 

• Signs/symptoms of infection 

• Symptom modifiers (medications, rest, ice) 

• Functional limitations 

Social History: 

• Nature of work-especially noting if patient is at risk due to faulty lower extremity 

biomechanics or postural strain (prolonged standing) 

• Recreational activities-type, frequency/duration, terrain, footwear 

• Home environment-stairs, ADL’s 

• Support system-motivation, ability to follow up with recommendations and 

physical therapy plan of care 

Medications: 

• NSAIDS, injection of corticosteroid into bursa 

Test results: Review results of any recent lower extremity imaging (radiographs, CT 

scan, MRI). Prevalence of 2.5% on MRI in symptomatic adults. 4 

Physical Examination: 

This section is intended to capture the minimum data set and identify specific circumstance(s) that might 

require additional tests and measures. 




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• Pain: typical presentation is pain localized to the anteromedial aspect of the knee, 

4 to 5 cm below the joint line, often exacerbated by knee flexion. 3 

• Palpation: tenderness over the affected bursa, with swelling, erythema and 

warmth 

• 

• Lower quarter screen: 

-Active and passive ROM of hip, knee and ankle joints, joint play 

-Patellar mobility and tracking 

-lower extremity manual muscle testing (if condition is chronic, the 

affected limb may show disuse atrophy and weakness) 

• Tests: 

-Thomas test, hamstring flexibility, leg length measurement, McMurray’s, 

ligamentous stability tests, Faber and Scour tests 

• Posture: 

Note hip posture: IR/ER of hip 

Note knee posture: varus/valgus, hyperextension, flexion contracture 

Note foot posture: pes planus/cavus, hallux valgus 

Note if any weight-bearing avoidance or intolerance on affected extremity 

• Gait: 

-Analysis gait during stance and swing phases of cycle 

-Stride length 

-Dynamic standing balance 

-Stair climbing 

-Assistive devices 

-Footwear 

• Sensation 

• Lower extremity functional scale (LEFS) 

Differential Diagnosis: 3,4 

• Stress fracture 

• Degenerative joint disease 

• Meniscal injury 

• Collateral ligament injury 

• Atypical medial meniscal cysts 

• Juxtarticular bone cysts 

• Semimembranosus bursitis 

• Tibial collateral ligament bursitis 

• Saphenous nerve entrapment 5 




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Assessment: 

Problem List: likely to include but not limited to: 

• Pain 

• Decreased ROM 

• Decreased muscle strength 

• Gait deviations 

• Decreased function 

• Postural dysfunction/impaired lower extremity biomechanics 

• Knowledge deficit: condition, self-management, home program, 

prevention 

Prognosis: Good to excellent with compliance to prescribed medical and rehabilitation 

management 

Goals: 

1) Decreased pain 

2) Increased ROM 

3) Increased muscle strength 

4) Improved gait quality and efficiency 

5) Maximize return to pre-injury activities 

6) Improved lower extremity biomechanics 

7) Independent self-management of symptoms; independence with home 

exercise program; independence with prevention of re-injury/re-occurrence 

Age Specific Considerations: Pes anserine bursitis can occur at any age, but is common 

in middle-aged women with knee osteoarthritis. 3 Individuals with associated 

comorbidities will require more careful goal setting and treatment planning which 

consider specific factors that maybe influencing the complete recovery of function. 

Treatment Planning / Interventions: 

Established Pathway ___ Yes, see attached. _X__ No 

Established Protocol ___ Yes, see attached. __X_ No 

Interventions most commonly used for this case type/diagnosis: 

1. NSAIDs 

2. Corticosteriod injection 

3. Therapeutic exercises to increase lower extremity muscle strength and 

flexibility, to decrease friction on the bursa and improve joint mechanics 




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4. Modalities such as ice, ultrasound and high-voltage electrical stimulation to 

decrease inflammation and pain 

5. Gait training for efficient and effective pattern (consider DME as appropriate) 

6. Orthotic consultation 

7. Instruction in home exercise program 

Frequency & Duration: 1-2x/week for 4-6 weeks 

Patient / family education: 

1. Home exercise program 

2. Sports specific training 

3. Pain and edema management 

Recommendations and referrals to other providers: 

1. Orthopedist 

2. Orthotist 

3. Rheumatologist 

4. Physiatrist 

5. PCP 

Re-evaluation / assessment 

Time Frame: every 30 days and/or prior to visit with physician 

Other Possible Triggers for re-evaluation are: 

1. Significant change in the signs and symptoms, fall or acute trauma 

2. Failure to progress per established short-term goals 

3. Complications or worsening of associated conditions 

Discharge Planning 

Commonly expected outcomes at discharge: 

1. Resolution of pain 

2. Increased AROM and strength 

3. Increased lower extremity muscle flexibility 

4. Return to pre-injury function and sports activities 

Patient’s discharge instructions: 

1. Progressed home exercise program 

2. Sports specific training 

3. Injury prevention 




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Bibliography / Reference List 

1. American Academy of Orthopaedic Surgeons. Goosefoot (Pes Anserine) Bursitis of the Knee. 

Available at: www.aaos.org. Accessed May 15, 2000. 

2. Saidoff DC, McDonough AL. Knee and shin. In: Critical Pathways in Therapeutic 

Intervention. Extremities and Spine. 1st ed. St. Louis: Mosby; 2002:546. 

3. Butcher JD, Salzman KL, Lillegard WA. Lower extremity bursitis. Am Fam Physician. 

1996;53:2317-2324. 

4. Rennie WJ, Saifuddin A. Pes anserine bursitis: Incidence in symptomatic knees and clinical 

presentation. Skeletal Radiol. 2005;34:395-398. 

5. Hemler DE, Ward WK, Karstetter KW, Bryant PM. Saphenous nerve entrapment caused by 

pes anserine bursitis mimicking stress fracture of the tibia. Arch Phys Med Rehabil. 

1991;72:336-337. 

Developed by: Reviewed by: Sharon Alzner, PT 1/06 

Marie-Josee Paris, PT 12/05 Ethan Jerome, PT 1/06 

Joan Casby, PT 2/06 




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Pes Anserine Bursitis - Brigham and Women's Hospital

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